Rural Healthcare Workforce

Maintaining the healthcare workforce is fundamental to providing access to quality healthcare in rural areas.
Rural healthcare facilities must employ enough healthcare professionals to meet the needs of the community. They
must have proper licensure, adequate education and training, and cultural competency skills. Equally important,
optimizing how health professionals are used and enhancing coordination among them helps ensure that patients
are getting the best care possible.

Strategies can include:

Using interprofessional teams to provide coordinated and efficient care for patients and to extend the reach
of each provider

Ensuring that all professionals are fully utilizing their skill sets and working at the top of their
license; that is, practicing to the full extent of their training and allowed scope of practice.

Removing state and federal barriers to professional practice, where appropriate

Removing barriers to the use of telehealth to provide access to distant healthcare providers

As the United States struggles with healthcare provider shortages, an uneven distribution of workers means that
shortages are often more profound in rural areas. This maldistribution is a persistent problem affecting the
nation's healthcare system.

Why is there a healthcare workforce shortage in rural areas?

According to the National Rural Health Association (NRHA) policy brief Health
Care Workforce Distribution and Shortage Issues in Rural America, healthcare labor shortages are an
ongoing problem, and are not expected to improve significantly in the near future. Shortages of rural healthcare
providers sometimes reflect national shortages of certain types of healthcare professionals.

Whether shortages exist in rural communities and how severe they are can be difficult to determine since
estimates of supply and demand for specific professions are not always available.

Rural communities are also affected by maldistribution of healthcare professionals. The Robert Wood
Johnson Foundation policy brief Primary Care Workforce
in the United States says that maldistribution of primary care providers is a greater problem affecting
healthcare access than shortages of providers. Areas with higher proportions of low-income and minority
residents, such as rural areas, tend to suffer most from lower supply of physicians and other health
professionals.

Access to training and education programs may be limited in rural areas for people who want to
pursue careers in healthcare.

Providers trained in urban areas may not be prepared for the challenges of working in rural
communities.

Urban areas sometimes draw people away from rural areas. Students in rural communities may have to
travel or relocate to an urban area for health professions coursework unless they can find degree
programs offered online, or for clinical training. Some may remain there after completion of their
studies.

There are fewer medical role models in rural communities.

Rural secondary school students may have fewer opportunities to receive the required math and
science courses needed to pursue health careers.

Rural Demographics and Health Status

Rural populations usually have higher rates of chronic illness, which creates more demand.

Rural areas tend to have higher proportions of elderly residents, who typically require more care.

Rural Practice Characteristics

The current healthcare system is designed around face-to-face contact. When rural communities lack
certain types of providers, particularly specialists, patients must travel longer distances or
forego care.

Barriers such as reimbursement policies and lack of broadband availability have hindered
telehealth adoption in some rural areas.

How are HPSA designations determined?

The primary factor used to determine whether a location may be designated as a HPSA is the number of full-time
equivalent healthcare professionals relative to the population, with consideration given to high-need indicators
such as a high percentage of the population living at or below 100% of the federal poverty level (FPL).

Where are HPSAs located in rural areas?

The following maps show designated HPSAs for primary care, dental health, and mental health.

To search for HPSAs by state and county, see HRSA's HPSA Find tool. For statistics
on HPSAs, including national percentages of HPSAs located in rural and urban areas, see the data.HRSA.gov
Designated
HPSA Statistics.

Medically Underserved Areas (MUAs) and Medically Underserved Populations (MUPs) are additional federal shortage
designations that indicate a lack of primary care services for an area or a population. MUAs and MUPs are based
on four factors, including:

Ratio of population to primary care providers

Infant mortality rate

High poverty level

Percentage of population over age 65

A list of MUAs and MUPs can be found at HRSA's Data
Portal Results. To search for MUAs and MUPs by state and county, visit HRSA's website, MUA Find.

The following chart shows rates of providers in rural areas as compared with urban areas for selected
professions. For more information about the number of providers in each profession, as well as data on other
health-related professions, see the fact
sheet.

The primary care physician workforce is also aging, which is likely to lead to increasing retirements in coming
years. According to a report
from the Association of American Medical Colleges, 44.5% of Family Medicine/General Practice physicians were age
55 or older as of 2015. A census
conducted by the Federation of State Medical Boards showed that 29% of actively licensed physicians were 60
years of age or older as of 2016, as compared with 25% in 2010.

Rural Physician Assistants (PAs)

According to a June 2018 report
from the American Academy of PAs, as of 2017:

About 16% of all PAs in clinical practice were located in rural counties

39% of these rural PAs were practicing in primary care, compared with 21% of urban PAs

Family medicine was the primary specialty of 33% of rural PAs, in contrast to 14% of those in urban areas

11% of rural PAs and 9% of urban PAs practice emergency medicine

Urgent care medicine is practiced by 9% of rural PAs and 6% of PAs in urban areas

Few PAs own their own practices: Only 2% of rural PAs and 1% of urban PAs

19% of rural PAs are age 55 or older, as compared with 13% of urban PAs

Rural Registered Nurses (RNs)

Nearing retirement – Nearly one million RNs who are older than 50, about 1/3 of the current
workforce, will reach retirement age in the next decade.

More likely to be white – 91.2% of RNs working in rural areas are white, compared with
72.4% of RNs in urban areas.

Less likely to have a bachelor's degree – 51.6% of RNs working in rural areas have a
nursing diploma or an associate's degree as their highest level of education, compared with 35.3% of
their urban counterparts.

Less likely to work for a hospital – 59.4% of RNs working in rural areas are employed in
hospitals compared with 63.9% of urban RNs.

About 16% of the RN workforce – From 2008 to 2010, there were 2.8 million RNs in the
workforce. Of that number, 445,000 live in rural areas.

Rural Licensed Practical Nurses (LPNs)

More likely to be white – 83.2% of rural LPNs are white, compared with 56.9% of LPNs in
urban areas.

Less likely to work for a hospital – 28.8% of LPNs working in rural areas are employed in
hospitals, compared with 29.5% of urban LPNs.

More likely to work in a nursing care facility – 33.5% of rural LPNs work in nursing care
facilities, compared with 29.8% of urban LPNs.

Same age as urban LPNs – The average age of both rural LPNs and urban LPNs is 43.6.

About 24% of the LPN workforce – From 2008 to 2010, there were 690,000 LPNs in the nursing
workforce. Of that number, 166,000 lived in rural areas. Thus, LPNs are disproportionately employed in rural
areas.

Increasing the number of healthcare graduates prepared for rural practice produced by state schools, by
supporting the development and growth of healthcare education programs with rurally-oriented curricula

Policy options that states can use to address rural health workforce shortages include:

Removing barriers to practice, such as allowing telehealth services to be provided across state lines

Allowing new or alternative provider types to practice in rural areas

What can schools do to meet rural healthcare workforce needs?

Options include:

Using admissions criteria that are likely to produce providers interested in rural practice, such as
admitting more students from rural communities

Offering rural-centric curricula and training tracks

Developing distance education programs

What strategies can rural healthcare facilities use to help meet their workforce needs?

Rural healthcare facilities can employ numerous strategies to ease healthcare workforce shortages and improve
care. For instance, they can employ technology, such as telehealth, to fill gaps in care caused
by shortages. In addition, facilities can use interprofessional care teams to provide more
efficient and high-quality care. Redesigning practice and processes to allow professionals to work at
the top of their license and skill set can also lessen the effects of shortages.

Rural areas often experience difficulties related to recruitment and retention of primary care physicians and
other health professionals. Thus, it is important to plan for future workforce needs. By
anticipating retirements and departures of staff, administrators can take steps to recruit replacements in a
timely manner, and avoid prolonged vacancies at their facilities. Increasing pay, benefits, and flexibility can
also improve chances for success with recruitment and retention.

Many rural communities recruit foreign medical graduates with J-1 visa
waivers to fill physician vacancies. The Conrad State 30 Program allows each state's health department
to request J-1 Visa Waivers for up to 30 foreign physicians per year. The physicians must agree to work in a
federally designated Health Professional Shortage Area (HPSA) or Medically Underserved Area (MUA). Interested
parties should contact the Primary
Care Office in the state where they intend to work, for more information and exact requirements. See
RHIhub's Rural J-1 Visa Waiver topic guide for details.

In addition to the J-1 visa waiver, non-immigrant H-1B visas are sometimes used to fill employment gaps. These
are employer-sponsored visas for “specialty occupations,” including medical doctors and physical
therapists. H-1B visas are issued for three years and can be extended to six years. For more information, see
the U.S. Citizenship and Immigration pages on the H-1B
Program and H-1B
Specialty Occupations.

Where can I find statistics on healthcare workforce for my state, including data on employment, projected
growth, and key environmental factors?

The Association of American Medical Colleges (AAMC)'s 2017
State Physician Workforce Data Book provides data on physician supply, medical school enrollment, and
graduate medical education throughout the United States.

What are some federal policies and programs designed to improve the supply of rural health professionals?

Area Health
Education Centers (AHEC) Program
AHECs promote interdisciplinary, community-based training initiatives intended to improve the diversity,
distribution, supply, and quality of healthcare personnel, particularly in primary care. The emphasis is on
delivery sites in rural and underserved areas. AHECs act as community liaisons with academic institutions and
assist in arranging training opportunities for health professions students, as well as K-12 students.

Health Careers Opportunity Program (HCOP)
HCOP works to increase the number of people from economically disadvantaged backgrounds who enter the health
professions field. HCOP programs provide student stipends and financial support to attend health professions
schools, training for disadvantaged students, and counseling and mentoring services to help students complete
their education and training. Students are exposed to community-based primary healthcare experiences.

National Health Service Corps (NHSC)
NHSC offers scholarships and loan repayment programs, which can enable students to complete health professions
training. Students must agree to complete a service commitment in a Health Professional Shortage Area. As
reported in A 21st Century
Health Care Workforce for the Nation, approximately 45% of NHSC providers serve in rural sites, and in
26 states rural NHSC providers outnumber urban.

NURSE Corps Scholarship Program
This program provides scholarships to nursing students who agree to serve 2 years at an eligible facility with a
shortage of nurses. Scholarships consist of payments for tuition, fees, other reasonable costs, and a monthly
stipend.

Where can states get technical assistance for health workforce planning, including how to address rural needs?

The Rural Health Information Hub is supported by the Health Resources
and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS)
under Grant Number U56RH05539 (Rural Assistance Center for Federal Office of Rural Health
Policy Cooperative Agreement). Any information, content, or conclusions on this website are
those of the authors and should not be construed as the official position or policy of, nor
should any endorsements be inferred by HRSA, HHS or the U.S. Government.